Nutritional approach for inhibiting bone resorption in institutionalized elderly women with vitamin D insufficiency and high prevalence of fracture

The effect of cheese intake on osteoarthritis: a Mendelian randomization study

Introduction

Osteoarthritis (OA) is a debilitating chronic disease with a high prevalence, characterized by progressive degeneration of articular cartilage that leads to joint dysfunction, pain, and disability. Observational studies investigating the link between cheese intake and OA have yielded inconclusive results and may be susceptible to confounding.

Material and methods

We performed a two-sample Mendelian randomization (MR) investigation to evaluate the causal association between cheese intake and OA based on genome-wide association studies (GWAS). The primary analysis employed the inverse variance weighted (IVW) method, while complementary analyses were conducted using the weighted median, MR-Egger, and weighted mode methods. Moreover, we weighted each single nucleotide polymorphism's (SNP) effect on OA by its effect on cheese intake and subsequently meta-analyzed these estimates utilizing a fixed-effects model to provide a summary effect estimate. To assess the robustness of the outcomes, we performed a sensitivity analysis.

Results

Our two-sample MR analysis revealed an inverse causal relationship between cheese intake and several types of OA, including self-reported OA (odds ratio (OR) = 0.96, 95% confidence interval (CI) = 0.94-0.97, p = 6.70 × 10-7), OA of the hip or knee (OR = 0.59, 95% CI = 0.48-0.72, p = 1.38 × 10-7), knee OA (OR = 0.52, 95% CI = 0.42-0.66, p = 4.11 × 10-8), and hip OA (OR = 0.72, 95% CI = 0.53-0.96, p = 0.0268). Additionally, the fixed-effects model also demonstrated a causal inverse association between cheese intake and OA, with a pooled meta-analysis OR of 0.95 (95% CI = 0.94-0.97, p < 0.0001).

Conclusions

Our findings provided compelling genetic evidence of causal inverse associations between cheese intake and various types of OA, including self-reported OA, OA of the hip or knee, knee OA, and hip OA, which may enhance the efficacy of OA prevention by deepening our comprehension of the involved risk factors.

Fermented Dairy Products, Musculoskeletal and Mental Health in Older Adults: is There Evidence to Support Benefits that go Beyond Those of Non-Fermented Dairy Products?

Fermented dairy products have recently gained popularity due to their purported health benefits, nevertheless, their role in ageing remains uncertain. This narrative review aims to evaluate evidence from observational (prospective) and interventional studies on the potential benefits of fermented dairy product consumption for musculoskeletal and mental health in older adults. Additionally, it seeks to determine whether any observed benefits surpass those of non-fermented dairy products and to identify directions for future research. Prospective studies support either favourable or neutral associations of fermented dairy products with outcomes of musculoskeletal health or neutral associations with mental health outcomes, whilst it remains unclear if the benefits observed with fermented dairy products go beyond those of the non-fermented dairy foods. Few interventional studies suggest overall favourable effects of yogurt and cheese on musculoskeletal health in older adults but given their small number (N = 6) and heterogeneity, they do not allow a clear assessment or definitive recommendations for fermented dairy intake. Interventional studies reporting mental health outcomes are largely lacking for this age group (N = 1). Given the very limited evidence for the effectiveness of fermented dairy products, future well-designed prospective and randomized controlled trials are needed to better understand their benefits (especially compared to those of non-fermented dairy foods), their characteristics and the quantities required to offer protection against musculoskeletal and/or mental health ageing.

Vitamin D fortification of foods - sensory, acceptability, cost, and public acceptance considerations

In terms of vitamin D food fortification, there are a number of important considerations in relation to selection of the food vehicle and fortificant. While there has been much research focus on the ability of fortified foods to improve vitamin D status, other considerations, such as sensory properties and acceptability, cost, and public attitudes around vitamin D-fortified foods, have received less attention. Thus, the present narrative review aimed to summarize the existing knowledge around these important considerations. In summary, its findings suggest that: i) vitamin D addition to various food vehicles, at levels consistent with the supply of part or all the recommended intake, does not alter their sensory characteristics or overall acceptability; ii) overall, vitamin D fortification of foods is relatively cost-effective, despite the fact that some attitudinal studies highlighted participant concerns about the potential cost/expense of vitamin D-fortified foods; iii) evidence from various attitudinal studies suggest a high level of acceptance and/or purchase intention (i.e., extent to which customers are willing and inclined to buy) of vitamin D-fortified food products by the general public; and iv) there have been repeated calls for vitamin D public health educational/information campaigns to help educate consumers about the health risks associated with vitamin D deficiency and nutritional benefits associated with consumption of vitamin D-fortified foods. Such campaigns could positively mediate attitudes and acceptance of vitamin D-fortified foods amongst the public, and could also help address misconceptions and allay fears around vitamin D for concerned individuals. Lastly, the findings of the present review also highlight the existence of between-country differences, even within Europe, in relation to attitudes and purchase intention of vitamin D-fortified foods and the perceived appropriateness of certain food vehicles for vitamin D fortification, as well as the best mix of communication channels for a vitamin D public health educational/information campaign.

Vitamin D Deficiency Is Frequent in Patients with Rapidly Destructive Osteoarthritis-Data from a Single-Center Analysis

BACKGROUND

Rapidly destructive osteoarthritis (RDO) of the hip joint is characterised by the rapid destruction of the femoral head with or without acetabular involvement. There has been increasing interest in this disease over the past years; however, the entity is still poorly understood, and its pathophysiology remains unknown. Yet, there is ample evidence today that increased bone metabolism might play a role in the onset and progression of the disease. Vitamin D is of utmost importance to maintain a balanced bone metabolism. However, whether vitamin D deficiency is involved in disease development remains to be elucidated. Further, the vitamin D status of patients with RDO has not yet been analysed. For this reason, the objective of this study was to assess the vitamin D status of patients with RDO. Moreover, the aim was to clarify whether there is a difference in the vitamin D status of patients with RDO compared with patients with primary osteoarthritis (OA).

METHODS

In this single-centre analysis, the 25(OH)D, PTH, and calcium levels of 29 patients who presented with RDO between 2020 and 2022 were assessed.

RESULTS

Altogether, 97% of patients (28/29) were vitamin D deficient, a further 3% (1/29) were vitamin D insufficient, and not a single patient presented with a sufficient vitamin D status. Notably, the vitamin D levels of RDO patients (mean = 11.04 ng/mL) were significantly lower than the vitamin D levels of patients with OA (mean = 22.16 ng/mL, p = 0.001).

CONCLUSION

In conclusion, we found a widespread and high rate of vitamin D deficiency in patients with RDO. Hence, we believe that 25(OH)D status should routinely be analysed in these patients.

Mineral Supplements in Ageing

With advancing age, achievement of dietary adequacy for all nutrients is increasingly difficult and this is particularly so for minerals. Various factors impede mineral acquisition and absorption including reduced appetite, depressed gastric acid production and dysregulation across a range of signalling pathways in the intestinal mucosa. Minerals are required in sufficient levels since they are critical for the proper functioning of metabolic processes in cells and tissues, including energy metabolism, DNA and protein synthesis, immune function, mobility, and skeletal integrity. When uptake is diminished or loss exceeds absorption, alternative approaches are required to enable individuals to maintain adequate mineral levels. Currently, supplementation has been used effectively in populations for the restoration of levels of some minerals like iron, zinc, and calcium, but these may not be without inherent challenges. Therefore, in this chapter we review the current understanding around the effectiveness of mineral supplementation for the minerals most clinically relevant for the elderly.

Implementing micronutrient fortification programs as a potential practical contribution to achieving sustainable diets

Due to sustainability concerns related to current diets and environmental challenges, it is crucial to have sound policies to protect human and planetary health. It is proposed that sustainable diets will improve public health and food security and decrease the food system's effect on the environment. Micronutrient deficiencies are a well-known major public health concern. One-third to half of the world's population suffers from nutrient deficiencies, which have a negative impact on society in terms of unrealised potential and lost economic productivity. Large-scale fortification with different micronutrients has been found to be a useful strategy to improve public health. As a cost-effective strategy to improve micronutrient deficiency, this review explores the role of micronutrient fortification programmes in ensuring the nutritional quality (and affordability) of diets that are adjusted to help ensure environmental sustainability in the face of climate change, for example by replacing some animal-sourced foods with nutrient-dense, plant-sourced foods fortified with the micronutrients commonly supplied by animal-sourced foods. Additionally, micronutrient fortification considers food preferences based on the dimensions of a culturally sustainable diet. Thus, we conclude that investing in micronutrient fortification could play a significant role in preventing and controlling micronutrient deficiencies, improving diets and being environmentally, culturally and economically sustainable.

Fortification of Staple Foods for Household Use with Vitamin D: An Overview of Systematic Reviews

Vitamin D deficiency is a global public health concern with significant implications for bone health and chronic disease prevention. Our aim was to summarize the evidence from Cochrane and other systematic reviews evaluating the benefits or harms of vitamin D fortification of staple foods for household use. In April 2023, we systematically searched Ovid MEDLINE, Embase, Epistemonikos and the Cochrane Database of Systematic Reviews for systematic reviews investigating the effects of vitamin D fortification of food in general populations of any age. We used Cochrane methodology and assessed the methodological quality of included studies using AMSTAR (A MeaSurement Tool to Assess Systematic Reviews). We assessed the degree of overlap among reviews. All outcomes included in systematic reviews were assessed. The protocol is registered in PROSPERO (registration number: CRD42023420991). We included 27 systematic reviews out of 5028 records for analysis. Overall, 11 out of 12 systematic reviews calculating pooled estimates reported a significant increase in serum 25(OH)D concentrations. The mean change in serum 25(OH)D concentrations per additional 100 units of vitamin D ranged from 0.7 to 10.8 nmol/L. Fortification of food with vitamin D showed a reduction in the prevalence of vitamin D deficiency based on high-certainty evidence. Parathormone (PTH) levels were described to decrease, bone mineral density to increase, while the effects on other bone turnover markers were inconsistent. Fortification did not significantly impact most anthropometric parameters, but it seemed to positively influence lipid profiles. In summary, fortification of food with vitamin D results in a reduction of vitamin D deficiency and might increase serum 25(OH)D concentrations, to varying extents depending on the fortified vehicle and population characteristics. Additionally, fortification may have a positive impact on bone turnover and lipid metabolism but may only have a limited effect on anthropometric parameters.

Vitamin D deficiency in nursing home residents: a systematic review

CONTEXT

Vitamin D deficiency is a global public health issue, particularly in nursing home residents.

OBJECTIVE

This review critically summarizes the prevalence of vitamin D deficiency in nursing home residents worldwide. In addition, it outlines the effect of vitamin D intervention, alone or in combination with other nutrients or therapies, on improving vitamin D status and associated health outcomes in nursing home residents.

DATA SOURCES, EXTRACTION, AND ANALYSIS

Searches were conducted of electronic databases for articles published from 2010 to May 2021. After screening of the 366 papers initially identified, 58 articles were included.

CONCLUSIONS

A paucity of observational studies in nursing homes suggests a high prevalence of vitamin D deficiency ranging from 8% [25(OH)D <25 nmol/L], up to 94% [25(OH)D <50 nmol/L] in some cohorts where supplement use was low. Reported factors associated with deficiency and suboptimal vitamin D status include lack of sunlight exposure, poor dietary intake of vitamin D, limited vitamin D food fortification, frailty, poor renal function, and low use of vitamin D supplements. Residents who are severely deficient, deficient, or insufficient in vitamin D require remedial vitamin D supplementation prior to maintenance supplementation at doses >800 IU/day. High-dose vitamin D supplementation may reduce respiratory illness; however, supportive data are limited. Oral nutritional supplements, in combination with exercise, may benefit physical function and performance, whereas supplementation with vitamin D- and calcium-fortified foods has been associated with improved quality of life and reduced bone resorption. Globally, vitamin D deficiency is highly prevalent in nursing home residents. There is an urgent need for standardized dietary and supplementation guidelines to prevent deficiency in this vulnerable group.

Effect of Vitamin D-Enriched Gouda-Type Cheese Consumption on Biochemical Markers of Bone Metabolism in Postmenopausal Women in Greece

Considering the role of bone metabolism in understanding the pathogenesis of osteoporosis, the aim of the present study was to examine the effects of vitamin D-enriched cheese on the serum concentrations of the parathyroid hormone (PTH) and certain bone remodeling biomarkers in postmenopausal women in Greece. In a randomised, controlled dietary intervention, 79 postmenopausal women (55–75 years old) were randomly allocated either to a control (CG: n = 39) or an intervention group (IG: n = 40), consuming 60 g of either non-enriched or vitamin D3-enriched Gouda-type cheese (5.7 μg of vitamin D3), respectively, daily and for eight weeks during the winter. The serum concentrations of 25-hydroxy vitamin D (25(OH)D), PTH, bone formation (i.e., osteocalcin, P1NP) and bone resorption (i.e., TRAP-5b) biomarkers were measured. Consumption of the vitamin D-enriched cheese led to higher serum 25(OH)D concentrations of 23.4 ± 6.39 (p = 0.022) and 13.4 ± 1.35 (p < 0.001) nmol/L in vitamin D-insufficient women being at menopause for less and more than 5 years, respectively. In vitamin D-insufficient women that were less than 5 years at menopause, consumption of vitamin D-enriched cheese was also associated with lower serum PTH (Beta −0.63 ± 1.11; p < 0.001) and TRAP-5b (Beta −0.65 ± 0.23; p = 0.004) levels at follow-up, compared with the CG. The present study showed that daily intake of 5.7 μg of vitamin D through enriched cheese increased serum 25(OH)D concentrations, prevented PTH increase and reduced bone resorption in vitamin D-insufficient early postmenopausal women, thus reflecting a potential food-based solution for reducing the risk of bone loss occurring after menopause.

Role of food fortification with vitamin D and calcium in the bone remodeling process in postmenopausal women: a systematic review of randomized controlled trials

CONTEXT

Foods containing vitamin D reduce the deficiency of this vitamin and improve bone turnover.

OBJECTIVE

To discuss effects of the intake of vitamin D-fortified foods in isolated form or associated with calcium on bone remodeling in postmenopausal women.

DATA SOURCES

PubMed, Lilacs, Scopus, and Bireme databases. OpenThesis and Google Scholar were searched as "grey literature". Medical subject headings or similar terms related to food fortified with vitamin D and bone in postmenopausal women were used.

DATA EXTRACTION

Information was collected on study methodology and characteristics of studied populations; dosage; the food matrix used as the fortification vehicle; duration of intervention; dietary intake; 25-hydroxyvitamin D [25(OH)D] levels; serum parathyroid hormone (PTH) concentrations; bone resorption and/or formation markers (ie, carboxy terminal cross-linked telopeptide of type I collagen [CTX], tartrate-resistant acid phosphatase isoform 5b [TRAP5b], and procollagen type 1 N-terminal propeptide [P1NP]); main results; and study limitations.

DATA ANALYSIS

Five randomized controlled trials involving postmenopausal women were included. The mean ages of participants ranged from 56.1 to 86.9 years. Daily consumption of soft plain cheese fortified with 2.5 µg of vitamin D3 and 302 mg of calcium for 4 weeks resulted in a mean increase of 0.8 ng/mL in 25(OH)D and 15.9 ng/mL in P1NP levels compared with baseline, and decreased CTX, TRAP5b, and PTH values. A similar intervention for 6 weeks, using fortified cheese, showed a reduction only in TRAP5b values (-0.64 U/L). Yogurt fortified with 10 µg of vitamin D3 and 800 mg of calcium did not change P1NP values after 8 weeks of intervention, but was associated with decreases of 0.0286 ng/mL and 1.06 U/L in PTH and TRAP5b, respectively. After 12 weeks of eating the fortified yogurt, 25(OH)D levels increased by a mean of 8.8 ng/mL and PTH levels decreased in by a mean of 0.0167 ng/mL.

CONCLUSIONS

The interventions contributed toward the improvement of the bone resorption process but not to the bone formation process in postmenopausal women.

PROSPERO REGISTRATION NUMBER

CRD42019131976.

Milk proteins and their derived peptides on bone health: Biological functions, mechanisms, and prospects

Bone is a dynamic organ under constant metabolism (or remodeling), where a delicate balance between bone resorption and bone formation is maintained. Disruption of this coordinated bone remodeling results in bone diseases, such as osteoporosis, the most common bone disorder characterized by decreased bone mineral density and microarchitectural deterioration. Epidemiological and clinical evidence support that consumption of dairy products is beneficial for bone health; this benefit is often attributed to the presence of calcium, the physiological contributions of milk proteins on bone metabolism, however, are underestimated. Emerging evidence highlighted that not only milk proteins (including individual milk proteins) but also their derived peptides positively regulate bone remodeling and attenuate bone loss, via the regulation of cellular markers and signaling of osteoblasts and osteoclasts. This article aims to review current knowledge about the roles of milk proteins, with an emphasis on individual milk proteins, bioactive peptides derived from milk proteins, and effect of milk processing in particular fermentation, on bone metabolism, to highlight the potential uses of milk proteins in the prevention and treatment of osteoporosis, and, to discuss the knowledge gap and to recommend future research directions.

Effects of Dietary or Supplementary Micronutrients on Sex Hormones and IGF-1 in Middle and Older Age: A Systematic Review and Meta-Analysis

Observational research suggests that micronutrients may be protective for sarcopenia, a key health issue during ageing, potentially via effects on hormone synthesis and metabolism. We aimed to carry out a systematic review of RCTs investigating effects of increasing dietary or supplemental micronutrient intake on sex hormones and IGF-1 in individuals aged 45 years or older. We searched MEDLINE, EMBASE and Cochrane databases for RCTs reporting the effects of different micronutrients (vitamins A, C, D, or E; carotenoids; iron; copper; zinc; magnesium; selenium; and potassium) on sex hormones or IGF-1. Of the 26 RCTs identified, nine examined effects of vitamin D, nine of multi-nutrients, four of carotenoids, two of selenium, one of zinc, and one of vitamin E. For IGF-1 increasing vitamin D (MD: -0.53 nmol/L, 95% CI: -1.58, 0.52), multi-nutrients (MD: 0.60 nmol/L, 95% CI -1.12 to 2.33) and carotenoids (MD -1.32 nmol/L; 95% CI -2.76 to 0.11) had no significant effect on circulating concentrations. No significant effects on sex hormones of other micronutrients were found, but data were very limited. All trials had significant methodological limitations making effects of micronutrient supplementation on sex hormones unclear. Further high quality RCTs with physiological doses of micronutrients in people with low baseline intakes or circulating concentrations, using robust methodology, are required to assess effects of supplementation adequately.

Can foodservices in aged care homes deliver sustainable food fortification strategies? A review

Food fortification is used as a nutrition support strategy in aged care homes, for residents who are malnourished or at risk of malnutrition. The aim of this review was to determine the scope and strength of published works exploring relationships between food fortification strategies, mode of delivery and sustainability in aged care homes. Literature from four databases and grey literature was searched. A total of 3152 articles were screened. Seventeen studies were included. Results showed that the majority of studies used pre-made food fortification, rather than fortifying foods on-site. There was heterogeneity across studies, including the mode of delivery and ingredients used for food fortification. Only two studies measured any aspect of costs. No clear sustainable strategies for implementing food fortification in this setting could be identified. Research is required to provide further insight into the acceptability and sustainability of food fortification interventions.

Effects of Fermented Milk Products on Bone

Fermented milk products like yogurt or soft cheese provide calcium, phosphorus, and protein. All these nutrients influence bone growth and bone loss. In addition, fermented milk products may contain prebiotics like inulin which may be added to yogurt, and provide probiotics which are capable of modifying intestinal calcium absorption and/or bone metabolism. On the other hand, yogurt consumption may ensure a more regular ingestion of milk products and higher compliance, because of various flavors and sweetness. Bone mass accrual, bone homeostasis, and attenuation of sex hormone deficiency-induced bone loss seem to benefit from calcium, protein, pre-, or probiotics ingestion, which may modify gut microbiota composition and metabolism. Fermented milk products might also represent a marker of lifestyle promoting healthy bone health.

25-Hydroxyvitamin D as a Biomarker of Vitamin D Status and Its Modeling to Inform Strategies for Prevention of Vitamin D Deficiency within the Population

There is substantial evidence that the prevalence of vitamin D deficiency is unacceptably high in the population, and this requires action from a public health perspective. Circulating 25-hydroxyvitamin D [25(OH)D] is a robust and reliable marker of vitamin D status and has been used by numerous agencies in the establishment of vitamin D dietary requirements and for population surveillance of vitamin D deficiency or inadequacy. In a wider context, modeling of serum 25(OH)D data and its contributory sources, namely dietary vitamin D supply and UVB availability, can inform our understanding of population vitamin D status. The aim of this review is to provide the current status of knowledge in relation to modeling of such vitamin D-relevant data. We begin by highlighting the importance of the measurement of 25(OH)D and its standardization, both of which have led to new key data on the prevalence of vitamin D deficiency and inadequacy in North America and Europe. We then overview how state-of-the-art modeling can be used to inform our understanding of the potential effect of ergocalciferol and 25(OH)D on vitamin D intake estimates and how meteorological data on UVB availability, when coupled with other key data, can help predict population serum 25(OH)D concentration, even accounting for seasonal fluctuations, and lastly, how these in silico approaches can help inform policymakers on strategic options on addressing low vitamin D status through food-based approaches and supplementation. The potential of exemplar food-based solutions will be highlighted, as will the possibility of synergies between vitamin D and other dairy food-based micronutrients, in relation to vitamin D status and bone health. Lastly, we will briefly consider the interactions between season and vitamin D supplements on vitamin D status and health.

Association between Dairy Product Consumption and Incidence of Total Hip Arthroplasty for Osteoarthritis

OBJECTIVE

The aim of this prospective cohort study was to determine whether dairy product consumption was associated with the incidence of total hip arthroplasty for osteoarthritis (OA).

METHODS

There were 38,924 participants from the Melbourne Collaborative Cohort Study who had dairy product consumption recorded in 1990-1994. The incidence of total hip arthroplasty for OA during 2001-2013 was determined by linking cohort records to the Australian Orthopaedic Association National Joint Replacement Registry.

RESULTS

Over an average of 11.8 years of followup, 1505 total hip arthroplasties for OA were identified (524 in men, 981 in women). In men, a 1 SD increase in dairy product consumption was associated with a 21% increased incidence of total hip arthroplasty for OA (HR 1.21, 95% CI 1.10-1.33), with a dose-response relationship observed for quartiles of dairy product consumption (p for trend = 0.001). These results were independent of age, body mass index, country of birth, education, smoking status, vigorous physical activity, calcium supplementation, energy consumption, circulating 25-hydroxy vitamin D, hypertension, and diabetes. No significant association was observed for women (HR 1.02, 95% CI 0.95-1.09).

CONCLUSION

Increasing dairy product consumption was associated with an increased risk of total hip arthroplasty for men with OA, with no significant association observed for women. Understanding the mechanisms may help identify strategies to prevent hip OA, particularly for men.

Cheese as Functional Food: The Example of Parmigiano Reggiano and Grana Padano

Italian hard cooked types of cheese, like Parmigiano Reggiano and Grana Padano, are characterised by positive nutritional qualities. In fact, they contain substances that have particular biological activities, and therefore they can be fully considered, according to the definition given by the European Unit, as 'functional' foods. This short review concisely describes these components and the beneficial effects related to their activities. The description of the biologically active components has been organised in the following paragraphs: protein and peptides, fat and lipids, carbohydrates and prebiotics, probiotic bacteria, vitamins, mineral salts, and components of dairy products active in disease prevention. In particular, several known bioactive peptides were found in Parmigiano Reggiano cheese samples: for example, phosphopeptides, which are known for their mineral-binding capacity and vehiculation activity, peptides with immunomodulatory activity, and angiotensin-converting enzyme-inhibitory peptides with anti-hypertensive effects. Among lipids, the role of conjugated linoleic acid and other fatty acids present in these cheese types was taken into consideration. The presence of oligosaccharides with prebiotic properties and probiotic bacteria was also described. Finally, particular emphasis was given to highly available calcium and its impact on bone health.

Supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults

BACKGROUND

Supportive interventions such as serving meals in a dining room environment or the use of assistants to feed patients are frequently recommended for the management of nutritionally vulnerable groups. Such interventions are included in many policy and guideline documents and have implications for staff time but may incur additional costs, yet there appears to be a lack of evidence for their efficacy.

OBJECTIVES

To assess the effects of supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults.

SEARCH METHODS

We identified publications from comprehensive searches of the Cochrane Library, MEDLINE, Embase, AMED, British Nursing Index, CINAHL, SCOPUS, ISI Web of Science databases, scrutiny of the reference lists of included trials and related systematic reviews and handsearching the abstracts of relevant meetings. The date of the last search for all databases was 31 March 2013. Additional searches of CENTRAL, MEDLINE, ClinicalTrials.gov and WHO ICTRP were undertaken to September 2016. The date of the last search for these databases was 14 September 2016.

SELECTION CRITERIA

Randomised controlled trials of supportive interventions given with the aim of enhancing dietary intake in nutritionally vulnerable adults compared with usual care.

DATA COLLECTION AND ANALYSIS

Three review authors and for the final search, the editor, selected trials from titles and abstracts and independently assessed eligibility of selected trials. Two review authors independently extracted data and assessed risk of bias, as well as evaluating overall quality of the evidence utilising the GRADE instrument, and then agreed as they entered data into the review. The likelihood of clinical heterogeneity amongst trials was judged to be high as trials were in populations with widely different clinical backgrounds, conducted in different healthcare settings and despite some grouping of similar interventions, involved interventions that varied considerably. We were only able, therefore, to conduct meta-analyses for the outcome measures, 'all-cause mortality', 'hospitalisation' and 'nutritional status (weight change)'.

MAIN RESULTS

Forty-one trials (10,681 participants) met the inclusion criteria. Trials were grouped according to similar interventions (changes to organisation of nutritional care (N = 13; 3456 participants), changes to the feeding environment (N = 5; 351 participants), modification of meal profile or pattern (N = 12; 649 participants), additional supplementation of meals (N = 10; 6022 participants) and home meal delivery systems (N = 1; 203 participants). Follow-up ranged from 'duration of hospital stay' to 12 months.The overall quality of evidence was moderate to very low, with the majority of trials judged to be at an unclear risk of bias in several risk of bias domains. The risk ratio (RR) for all-cause mortality was 0.78 (95% confidence interval (CI) 0.66 to 0.92); P = 0.004; 12 trials; 6683 participants; moderate-quality evidence. This translates into 26 (95% CI 9 to 41) fewer cases of death per 1000 participants in favour of supportive interventions. The RR for number of participants with any medical complication ranged from 1.42 in favour of control compared with 0.59 in favour of supportive interventions (very low-quality evidence). Only five trials (4451 participants) investigated health-related quality of life showing no substantial differences between intervention and comparator groups. Information on patient satisfaction was unreliable. The effects of supportive interventions versus comparators on hospitalisation showed a mean difference (MD) of -0.5 days (95% CI -2.6 to 1.6); P = 0.65; 5 trials; 667 participants; very low-quality evidence. Only three of 41 included trials (4108 participants; very low-quality evidence) reported on adverse events, describing intolerance to the supplement (diarrhoea, vomiting; 5/34 participants) and discontinuation of oral nutritional supplements because of refusal or dislike of taste (567/2017 participants). Meta-analysis across 17 trials with adequate data on weight change revealed an overall improvement in weight in favour of supportive interventions versus control: MD 0.6 kg (95% CI 0.21 to 1.02); 2024 participants; moderate-quality evidence. A total of 27 trials investigated nutritional intake with a majority of trials not finding marked differences in energy intake between intervention and comparator groups. Only three trials (1152 participants) reported some data on economic costs but did not use accepted health economic methods (very low-quality evidence).

AUTHORS' CONCLUSIONS

There is evidence of moderate to very low quality to suggest that supportive interventions to improve nutritional care results in minimal weight gain. Most of the evidence for the lower risk of all-cause mortality for supportive interventions comes from hospital-based trials and more research is needed to confirm this effect. There is very low-quality evidence regarding adverse effects; therefore whilst some of these interventions are advocated at a national level clinicians should recognise the lack of clear evidence to support their role. This review highlights the importance of assessing patient-important outcomes in future research.

Food fortification for bone health in adulthood: a scoping review

Food fortification can deliver essential micronutrients to large population segments without modifications in consumption pattern, suggesting that fortified foods may be formulated for populations at risk for fragility fractures. This scoping review determined the extent to which randomized controlled studies have been carried out to test the impact of fortified foods on bone outcomes, searching PubMed for all studies using the terms 'fortified AND bone', and 'fortification AND bone'. Studies were restricted to English language, published between 1996 and June 2015. From 360 articles, 24 studies met the following criteria: human study in adults ⩾18 years (excluding pregnancy or lactation); original study of a fortified food over time, with specific bone outcomes measured pre- and post intervention. Six studies involved adults <50 years; 18 involved adults ⩾50 years. Singly or in combination, 17 studies included calcium and 16 included vitamin D. There were 1 or 2 studies involving either vitamin K, magnesium, iron, zinc, B-vitamins, inulin or isoflavones. For adults <50 years, the four studies involving calcium or vitamin D showed a beneficial effect on bone remodeling. For adults ⩾50 years, n=14 provided calcium and/or vitamin D, and there was a significant bone turnover reduction. No consistent effects were reported in studies in which addition of vitamin K, folic acid or isoflavone was assessed. Results from this scoping review indicate that up to now most studies of fortification with bone health have evaluated calcium and/or vitamin D and that these nutrients show beneficial effects on bone remodeling.

Micronutrient Food Fortification for Residential Care: A Scoping Review of Current Interventions

PURPOSE

Malnutrition is common in residential care environments, primarily due to poor intake. Micronutrient deficiency, although poorly investigated to date, is also reported to be high. Improving the nutrient density of consumed foods is a potential mechanism to promote increased nutrient intake. A scoping review was conducted to: (1) explore the evidence on micronutrient food fortification strategies, (2) identify candidate nutrients and food vehicles for successful food fortification, and (3) identify gaps for future research.

METHODS

The scoping review framework of Arksey and O'Malley was used. A comprehensive search strategy of 4 electronic databases (MEDLINE, EMBASE, CINAHL, and Web of Science) was completed. Two reviewers were involved in screening and data extraction for all selected articles.

RESULTS

A total of 4394 relevant articles were identified for screening, and application of inclusion/exclusion criteria resulted in 6 food fortification studies (8 citations; 1 study had 3 citations). Overall, vitamin D (n = 5 studies) and calcium (n = 4 studies) were the most common micronutrients fortified; milk products, margarine, bread, and pureed foods were fortification vehicles. Most studies fortified below the RDA recommendation and did not include clinical outcomes. Samples were small and intervention periods were short (3-6 months).

CONCLUSIONS

Fortification is a viable strategy for improving the nutrient density of foods consumed in residential care. Although disparate, this literature suggests the potential for further undertaking of fortification to prevent micronutrient deficiencies among residents and future research should consider multinutrient preparations and clinical outcomes.

Calcium plus vitamin D supplementation and risk of fractures: an updated meta-analysis from the National Osteoporosis Foundation

The aim was to meta-analyze randomized controlled trials of calcium plus vitamin D supplementation and fracture prevention. Meta-analysis showed a significant 15 % reduced risk of total fractures (summary relative risk estimate [SRRE], 0.85; 95 % confidence interval [CI], 0.73-0.98) and a 30 % reduced risk of hip fractures (SRRE, 0.70; 95 % CI, 0.56-0.87).

INTRODUCTION

Calcium plus vitamin D supplementation has been widely recommended to prevent osteoporosis and subsequent fractures; however, considerable controversy exists regarding the association of such supplementation and fracture risk. The aim was to conduct a meta-analysis of randomized controlled trials [RCTs] of calcium plus vitamin D supplementation and fracture prevention in adults.

METHODS

A PubMed literature search was conducted for the period from July 1, 2011 through July 31, 2015. RCTs reporting the effect of calcium plus vitamin D supplementation on fracture incidence were selected from English-language studies. Qualitative and quantitative information was extracted; random-effects meta-analyses were conducted to generate summary relative risk estimates (SRREs) for total and hip fractures. Statistical heterogeneity was assessed using Cochran's Q test and the I (2) statistic, and potential for publication bias was assessed.

RESULTS

Of the citations retrieved, eight studies including 30,970 participants met criteria for inclusion in the primary analysis, reporting 195 hip fractures and 2231 total fractures. Meta-analysis of all studies showed that calcium plus vitamin D supplementation produced a statistically significant 15 % reduced risk of total fractures (SRRE, 0.85; 95 % confidence interval [CI], 0.73-0.98) and a 30 % reduced risk of hip fractures (SRRE, 0.70; 95 % CI, 0.56-0.87). Numerous sensitivity and subgroup analyses produced similar summary associations. A limitation is that this study utilized data from subgroup analysis of the Women's Health Initiative.

CONCLUSIONS

This meta-analysis of RCTs supports the use of calcium plus vitamin D supplements as an intervention for fracture risk reduction in both community-dwelling and institutionalized middle-aged to older adults.

Biochemical markers for assessment of calcium economy and bone metabolism: application in clinical trials from pharmaceutical agents to nutritional products

Nutrition plays an important role in osteoporosis prevention and treatment. Substantial progress in both laboratory analyses and clinical use of biochemical markers has modified the strategy of anti-osteoporotic drug development. The present review examines the use of biochemical markers in clinical research aimed at characterising the influence of foods or nutrients on bone metabolism. The two types of markers are: (i) specific hormonal factors related to bone; and (ii) bone turnover markers (BTM) that reflect bone cell metabolism. Of the former, vitamin D metabolites, parathyroid hormone, and insulin-like growth factor-I indicate responses to variations in the supply of bone-related nutrients, such as vitamin D, Ca, inorganic phosphate and protein. Thus modification in bone remodelling, the key process upon which both pharmaceutical agents and nutrients exert their anti-catabolic or anabolic actions, is revealed. Circulating BTM reflect either osteoclastic resorption or osteoblastic formation. Intervention with pharmacological agents showed that early changes in BTM predicted bone loss and subsequent osteoporotic fracture risk. New trials have documented the influence of nutrition on bone-tropic hormonal factors and BTM in adults, including situations of body-weight change, such as anorexia nervosa, and weight loss by obese subjects. In osteoporosis-prevention studies involving dietary manipulation, randomised cross-over trials are best suited to evaluate influences on bone metabolism, and insight into effects on bone metabolism may be gained within a relatively short time when biochemical markers are monitored.

Dairy products, yogurts, and bone health

Fracture risk is determined by bone mass, geometry, and microstructure, which result from peak bone mass (the amount attained at the end of pubertal growth) and from the amount of bone lost subsequently. Nutritional intakes are an important environmental factor that influence both bone mass accumulation during childhood and adolescence and bone loss that occurs in later life. Bone growth is influenced by dietary intake, particularly of calcium and protein. Adequate dietary calcium and protein are essential to achieve optimal peak bone mass during skeletal growth and to prevent bone loss in the elderly. Dairy products are rich in nutrients that are essential for good bone health, including calcium, protein, vitamin D, potassium, phosphorus, and other micronutrients and macronutrients. Studies supporting the beneficial effects of milk or dairy products on bone health show a significant inverse association between dairy food intake and bone turnover markers and a positive association with bone mineral content. Fortified dairy products induce more favorable changes in biochemical indexes of bone metabolism than does calcium supplementation alone. The associations between the consumption of dairy products and the risk of hip fracture are less well established, although yogurt intake shows a weakly positive protective trend for hip fracture. By consuming 3 servings of dairy products per day, the recommended daily intakes of nutrients essential for good bone health may be readily achieved. Dairy products could therefore improve bone health and reduce the risk of fractures in later life.

Increasing dietary phosphorus intake from food additives: potential for negative impact on bone health

It is important to consider whether habitual high phosphorus intake adversely affects bone health, because phosphorus intake has been increasing, whereas calcium intake has been decreasing in dietary patterns. A higher total habitual dietary phosphorus intake has been associated with higher serum parathyroid hormone (PTH) and lower serum calcium concentrations in healthy individuals. Higher serum PTH concentrations have been shown in those who consume foods with phosphorus additives. These findings suggest that long-term dietary phosphorus loads and long-term hyperphosphatemia may have important negative effects on bone health. In contrast, PTH concentrations did not increase as a result of high dietary phosphorus intake when phosphorus was provided with adequate amounts of calcium. Intake of foods with a ratio of calcium to phosphorus close to that found in dairy products led to positive effects on bone health. Several randomized controlled trials have shown positive relations between dairy intake and bone mineral density. In our loading test with a low-calcium, high-phosphorus lunch provided to healthy young men, serum PTH concentrations showed peaks at 1 and 6 h, and serum fibroblast growth factor 23 (FGF23) concentrations increased significantly at 8 h after the meal. In contrast, the high-calcium, high-phosphorus meal suppressed the second PTH and FGF23 elevations until 8 h after the meal. This implies that adequate dietary calcium intake is needed to overcome the interfering effects of high phosphorus intake on PTH and FGF23 secretion. FGF23 acts on the parathyroid gland to decrease PTH mRNA and PTH secretion in rats with normal kidney function. However, increased serum FGF23 is an early alteration of mineral metabolism in chronic kidney disease, causing secondary hyperthyroidism, and implying resistance of the parathyroid gland to the action of FGF23 in chronic kidney disease. These findings suggest that long-term high-phosphorus diets may impair bone health mediated by FGF23 resistance both in chronic kidney disease patients and in the healthy population.

Nutrition and bone health: turning knowledge and beliefs into healthy behaviour

Primary osteoporosis prevention requires healthy behaviours, such as regular physical exercise and adequate dietary intakes of calcium, vitamin D and protein. Calcium and vitamin D can decrease postmenopausal bone loss and prevent fracture risk. However, there is still a high prevalence of calcium and vitamin D insufficiency in women aged 50+ years. Dietary sources of these nutrients are the preferred choice, and dairy products represent a valuable dietary source of calcium due to the high content, high absorptive rate and relatively low cost. Furthermore, dairy products also contain other key nutrients including vitamin D, phosphorus and protein that contribute to bone health. Studies of women's beliefs and behaviours with respect to osteoporosis highlight poor knowledge of the importance of dietary nutrient intakes and low concern regarding bone health. Osteoporosis educational programmes exist to help women change behaviours relevant to bone health. Such programmes can have positive influences on women's knowledge, attitudes, perceived norms, motivation and behaviours. Increased awareness of the consequences of low calcium and vitamin D intakes may promote women's attitudes towards dietary sources, in particular dairy products, and lead to better adherence to health recommendations. Increasing dietary nutrient intakes through educational initiatives should be further developed to aid the prevention of osteoporosis and the efficacy of osteoporosis management.

Consumption of yogurts fortified in vitamin D and calcium reduces serum parathyroid hormone and markers of bone resorption: a double-blind randomized controlled trial in institutionalized elderly women

CONTEXT

Nutritional prevention of bone deterioration with fortified foods seems particularly suitable in institutionalized elderly women at risk of vitamin D deficiency, secondary hyperparathyroidism, increased bone resorption, and osteoporotic fracture.

OBJECTIVE

The objective was to evaluate whether fortification of yogurts with vitamin D and calcium exerts an additional lowering effect on serum PTH and bone resorption markers as compared with isocaloric and isoprotein dairy products in elderly women.

DESIGN

A randomized double-blind controlled-trial, 56-day intervention was conducted in institutionalized women (mean age 85.5 years) consuming 2 125-g servings of either vitamin D- and calcium-fortified yogurt (FY) at supplemental levels of 10 μg/d vitamin D₃ and 800 mg/d calcium or nonfortified control yogurt (CY) providing 280 mg/d calcium.

MAIN OUTCOMES

The endpoints were serum changes from baseline (day 0) to day 28 and day 56 in 25-hydroxyvitamin-D (25OHD), PTH, and bone resorption markers tartrate-resistant acid phosphatase isoform-5b (TRAP5b), the primary outcome, and carboxyl-terminal cross-linked telopeptide of type I collagen (CTX).

RESULTS

At day 56, serum 25OHD increased (mean ± SEM) by 25.3 ± 1.8 vs 5.2 ± 2.5 nmol/L in FY (n = 29) and CY (n = 27), respectively (P < .0001). The corresponding changes in PTH were -28.6% ± 7.2% vs -8.0% ± 4.3% (P = .0003); in TRAP5b, -21.9% ± 4.3% vs 3.0% ± 3.2% (P < .0001); and in CTX, -11.0% ± 9.7% vs -3.0% ± 4.1% (P = .0146), in FY and CY, respectively. At day 28, these differences were less pronounced but already significant for 25OHD, PTH, and TRAP5b.

CONCLUSIONS

This study in institutionalized elderly at high risk for osteoporotic fracture suggests that fortification of dairy products with vitamin D₃ and calcium provides a greater prevention of accelerated bone resorption as compared with nonfortified equivalent foods.

Dairy in adulthood: from foods to nutrient interactions on bone and skeletal muscle health

The risk of fragility fractures exponentially increases with aging. Reduced mass and strength of both bone in osteoporosis and skeletal muscle in sarcopenia play a key role in the age-related incidence of fragility fractures. Undernutrition is often observed in the elderly, particularly in those subjects experiencing osteoporotic fractures, more likely as a cause than a consequence. Calcium (Ca), inorganic phosphate (Pi), vitamin D, and protein are nutrients that impact bone and skeletal muscle integrity. Deficiency in the supply of these nutrients increases with aging. Dairy foods are rich in Ca, Pi, and proteins and in many countries are fortified with vitamin D. Dairy foods are important souces of these nutrients and go a long way to meeting the recommendations, which increase with aging. This review emphaszes the interactions between these 4 nutrients, which, along with physical activity, act through cellular and physiological pathways favoring the maintenance of both bone and skeletal muscle structure and function.

The role of diet in osteoporosis prevention and management

Diet, a modifiable osteoporosis risk factor, plays an important role in the acquisition and maintenance of bone mass. The influence of diet on bone begins in childhood; even maternal diet can influence bone mass in the offspring. A good general nutritional status and adequate dietary protein, calcium, vitamin D, fruits, and vegetables have a positive influence on bone health, while a high caloric diet and heavy alcohol consumption have been associated with lower bone mass and higher rates of fracture. The evidence for a role of other minerals and vitamins in skeletal health is not as strong, but recent evidence suggests that vitamins C and K might also have an effect on bone.

Consumption of vitamin D-and calcium-fortified soft white cheese lowers the biochemical marker of bone resorption TRAP 5b in postmenopausal women at moderate risk of osteoporosis fracture

The prevention of increased bone remodeling in postmenopausal women at low 10-y risk of osteoporotic fractures essentially relies on reinforcement of environmental factors known to positively influence bone health, among which nutrition plays an important role. In institutionalized women in their mid-eighties, we previously found that consumption of fortified soft plain cheese increased vitamin D, calcium, and protein intakes, reduced bone resorption biochemical markers, particularly the serum bone specific acid phosphatase tartrate resistant acid phosphatase, isoform 5b (TRAP 5b) that reflects osteoclast activity, and stimulated the serum bone anabolic factor insulin-like growth factor-I (IGF-I). Whether these effects occur in much younger women was tested in a prospective control study. Seventy-one healthy postmenopausal women aged 56.6 ± 3.9 y (mean ± SD) with low spontaneous supply of both Ca and vitamin D were randomized to consume daily (treated, n = 36) or not (controls, n = 35) two servings (2 × 100 g) of skimmed-milk, soft plain cheese for 6 wk. The vitamin D and Ca-fortified dairy product provided daily: 661 kJ, 2.5 μg vitamin D, 400 mg calcium, and 13.8 g protein. At the end of the intervention, the decrease in TRAP 5b and the increase in IGF-I were greater in the treated than in the control group (P < 0.02). The changes in serum carboxy terminal crosslinked telopeptide of type I collagen did not differ significantly between the two groups. In conclusion, like in elderly women, consumption by healthy postmenopausal women of a vitamin D and calcium-fortified dairy product that also increases the protein intake, reduces the serum concentration of the bone resorption biomarker TRAP 5b. This response, combined with the increase in serum IGF-I, is compatible with a nutrition-induced reduction in postmenopausal bone loss rate.